Prior Authorization Request Form for Prescription Drugs

PRIOR AUTHORIZATION REQUEST FORM FOR PRESCRIPTION DRUGS

FAX this completed form to (866) 399-0929

OR Mail requests to: Envolve Pharmacy Solutions PA Dept. | 5 River Park Place East, Suite 210 | Fresno, CA 93720

I. Provider Information

Prescriber name (print):

II. Member Information

Member name:

Office contact name:

Identification number:

Group name:

Group number:

Fax:

Date of Birth:

Phone:

Medication allergies:

III. Drug Information (One drug request perform)

Drug name and strength:

Dosage form:

Diagnosis relevant to this request:

Expected length of therapy:

Dosage Interval (sig):

Qty per Day:

Medication History for this Diagnosis

A. Is member currently treated on this medication?

yes; How Long?

[go to item B]

no [skip items B & C; go to item D]

B. Is this request for continuation of a previous approval?

yes [go to item C]

no [skip item C; go to item D]

C. Has strength, dosage, or quantity required per day increased or decreased?

yes [go to item D]

no [skip item D; indicate rationale for continuation in Section IV and submitform]

D. Please indicate previous treatment and outcomes below.

Drug Name

Dates of Therapy

(include strength and dosage)

1

Reason for Discontinuation

2 3

4

NOTE: Confirmation of use will be made from member history on file; prior use of preferred drugs is a part of the exception criteria. The Ambetter Formulary is available on the Ambetter website at (search for your state to view your specific formulary document.)

IV. Rationale for Request / Pertinent Clinical Information (Required for all Prior Authorizations)

Appropriate clinical information to support the request on Provider Signature: the basis of medical necessity must besubmitted.

Date:

Envolve Pharmacy Solutions and Ambetter will respond via fax or phone within 24 hours of receipt of all necessary information, except during weekends or holidays. Requests for prior authorization (PA) requests must include member name, ID#, and drug name. Incomplete forms will delay processing. Please include lab reports with requests when appropriate (e.g., Culture and Sensitivity; Hemoglobin A1C; Serum Creatinine; CD4; Hematocrit; WBC, etc.)

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